Section: AGN Number: Chapter: Originated: 6/08 Last Reviewed: 6/08 Title: Narcotic Pain Management Policy Approved:

P Kullberg Contact: Susan Kirchoff

Patients Rights: 1. Considerate and respectful care that accepts and acts upon reports of pain 2. Thorough assessment and management of pain regardless of cause or severity 3. Full disclosure of diagnosis and prognosis of condition, proposed treatments and their benefits, risks and costs 4. Full participation in decisions about pain management, including the right to refuse specific treatments 5. Privacy concerning all aspects of care Patient Responsibilities 1. 2. 3. Participate in and cooperate with all aspects of pain care Refrain from all alcohol and drug use or abuse Disclose all alcohol or drug use, past or current 4. Disclose all visits to emergency rooms or other providers, including mental health providers 5. If on probation or parole, sign a release of information to parole or probation officer 6. Keep all appointments and adhere to the schedule of refills agreed upon with provider Comply with all provider dosing recommendations Agree to regular and random pill counts Agree to regular and random urine drug screens 10. Refrain from giving pain medications away to others or borrowing pain medications from others 11. Obtain pain medicine prescriptions only from the primary care provider or covering provider at the same clinic New patients: 1. Low risk for abuse and/or diversion: provider to manage at his/her discretion (see Opiate Risk Tool) 2. Moderate or high risk for abuse and/or diversion (see Opiate Risk Tool) or discharged from or left other health care systems because of problematic behaviors:

7. 8. 9.

 Must be enrolled in nurse case management for pain (See Opiate Risk Tool and Pain Management Protocol below) Restrict to MCHD pharmacy for easier oversight of prescriptions, unless this represents a hardship for the patient 3. Patient with documented instances of selling drugs (an absolute contraindication) should not be considered for narcotic pain management 4. Patients with documented history of intentional or unintentional overdose of narcotics requiring emergency intervention and patients with documented history of prescription forgery for their own use are not good candidates (relative contraindication) for narcotic pain management. If narcotics are prescribed, these high risk patients must be enrolled in nurse case management and other controls should be considered such as bubble-packing, daily dispensing, etc. Transfer of Established patients Patients, who have a pain management agreement, are dissatisfied with care or have problematic behaviors and who want to transfer to another provider or another clinic within MCHD: Avoid changing the patients medical home Prior to transfer, if possible, refer case to clinic management and to Opiate Oversight Committee (see below) Clinic manager should counsel patient that current pain management regimen will be continued by new provider, pending recommendations from Opiate Oversight Committee. Many of these patients will simply show up in the new PCP practice; refer patient to Opiate Oversight Committee at that time New PCP may consider fresh start if: 1. systems issues interfered with appropriate care of patient in prior practice (for example, patient denied meds because old records were never received, but ROI process was never completed by staff) 2. patient condition or circumstances have substantially changed (for example, patient successfully graduated from drug treatment program) If new PCP grants fresh start, the patient must be enrolled in nurse case management and restricted to MCHD pharmacy Dissatisfied patients may elect to submit an appeal to the opiate oversight committee Cross Coverage 1. When PCP is absent, covering provider will honor refill requests for narcotic pain medications if: Pain medication agreement is in record No violations of the agreement are apparent Refill due date is clearly documented 2. Covering provider may elect to:

Give partial prescription pending PCP return Order UDS Deny refill for any of above conditions

Prescriptions and Refills 1. Narcotic prescription on a first visit is at provider discretion (it is acceptable to request a ROI and/or copies of medical records before prescribing). 2. A narcotic prescription on a first visit may be appropriate if the patient is low risk and sufficient documentation is available to ensure that there is no history of prior problem behaviors 3. Prescribing narcotics at a first visit for a patient who might be at risk for withdrawal must be weighed against the risk of abuse and/or diversion 4. Lost or stolen narcotics will not be replaced 5. Early refills should be avoided, but may be given at PCP discretion for compelling reasons. PCP should document the reason for the early refill and document on the prescription the appropriate date for the next refill. PCP should also advise patient that early refills will not be given on a routine basis. will not be given 6. Refills will not be given after normal clinic hours, on weekends or holidays 7. All refills must be obtained through a single designated pharmacy 8. All refills must be obtained through the PCP or in his/her absence, the practice partner 9. Refill requests submitted after 12 pm on Fridays may not be authorized until the following work day 10. Dosing adjustments will be made only by the PCP unless s/he is on a prolonged leave of absence (>= four weeks) 11. All prescriptions will be written for 28 day cycles and scheduled to fall due on a day when PCP is normally in clinic 12. Authorize no more than 2 (original plus 2) refills total for Schedule III narcotics and only for low risk patients 13. Up to three 28 day prescriptions for Schedule II narcotics can be written on the same date with instructions to be filled at later dates, per established EHR protocol, only for low risk patients. Pre-dated prescriptions which are lost or stolen may not be replaced. 14. Patients on chronic narcotics should be seen by the nurse or PCP at least every 3 months and by the PCP at least every 6 months Opiate Oversight Committee 1. The purpose of the Opiate Oversight Committee is to review cases and make recommendations for clinical management of chronic pain patients taking opiate pain medications or who wish to take opiates. Providers/Provider Team may refer to the Committee any patient for whom they wish a second opinion on the best

course of action. Referrals are voluntary at provider discretion. Clinic management may also refer patients. Patients may self-refer. 2. Appropriate referrals to the Committee can include: Contemplated dismissal of patient from opiate pain management for problematic behaviors Patient disputes provider judgment Patient request to transfer PCP because of pain management issues Management/interpretation of UDS findings Total opiate dose exceeds 180 mg morphine equivalent ceiling 3. The opiate oversight committee will consist of Medical Director and Asst Medical Director Clinic Lead Providers One nursing supervisor One licensed clinical social worker Pharmacist Psychiatric Nurse Practitioner as specialty consultants as needed 4. Committee meets monthly to consider referrals 5. Recommendations of the oversight committee are not binding; the PCP bears final responsibility for clinical decisions. The PCP may request to make the Oversight Committee recommendations binding.

Practice Guidelines for Treatment of Chronic Pain Syndromes

(Guidelines for assessment and management of specific diagnoses or pain syndromes are not included)

Assessment Provider must perform independent and comprehensive assessment of all pain complaints, including review of old records. Substance use/abuse history should be assessed. Treatment of chronic pain with narcotic analgesia prior to establishing a diagnosis is not recommended. Consent Narcotic consent and agreement must be completed and signed for all patients receiving regular prescriptions of narcotics for chronic pain (see attached AGN.06.01) Urine Drug Screen consent must be obtained separately if a UDS is ordered prior to prescribing narcotics. All consents must be scanned into the EHR Dosing strategies and considerations 1. Preferred short-acting agents: oxycodone and hydrocodone 2. Preferred long-acting agents: methadone and extended release morphine (see attached prescribing guidelines for methadone). Methadone i. Potent and effective long-acting opioid ii. Onset of Action (oral analgesic): 30-60 mins iii. Duration: Oral: 6-8 hours, increases to 22-48 hours with repeated doses iv. Half-life elimination: varies, but takes 5-7 days to reach steady state (effects on respiration last longer than anesthesia) v. Check for drug-drug interactions

vi. Consider written consent (see attachment AGN.01.13); the general narcotic pain agreement must be done as well. vii. GO LOW, GO SLOW. Start at 5-15 mg total daily dose split BID or TID. DO NOT adjust dose more often than 5-7 days 3. More than 40 mg of oxycodone or 60 mg hydrocodone per day should prompt a switch to a long-acting opiate. Most chronic pain patients feel better on a longacting preparation. Resistance to taking a long-acting drug should prompt suspicion of abuse or diversion. 4. Morphine Adjust dose for renal impairment 5. Fentanyl patch Caution patient not to alter the patch Rotate sites of application Dose effects may last longer than 24 hours Do not adjust dose more often than q 3-6 days 6. Not recommended for chronic, non-malignant pain Meperidine (Demerol). Combination agonists and mixed agonists/antagonists such as butorphanol (Stadol), dezocine (Dalgan), nalbuphine (Nubain) and pentazocine (Talwin) Parenteral medications 7. Total opiate dose, long-action plus short-acting medications, should not exceed 180mg morphine oral equivalents per day. If prescribing more than 180 mg morphine dose equivalents (total opiate dose) per day, consider pain management consultation or 2nd opinion from a colleague or referral to opiate oversight committee. .

Drug Morphine Codeine Hydrocodone Hydromorphone Oxycodone Methadone

Equianalgesic Dose 30mg 200mg 30mg 7.5mg 20mg 10mg (chronic)

Adult starting dose/day 30mg 60-120mg 10-20mg 6-8mg 10-20mg 5-15mg

Ceiling dose/day (as single agent) 180mg 1200mg 180mg 45mg 120mg 60mg

8. When starting opiates, dose increases may need to be made to optimize pain control and maximize functional status Do not continue to increase the dose of an opiate that is not providing incremental pain relief Frequent requests to escalate dose may indicate patient is treating psychiatric symptoms with opiates; consider psychiatric evaluation if not already done Counsel patient about tolerance Side Effect Management 1. Constipation Manage proactively with stool softeners, bulking agents (psyllium), or osmotic agents (Milk of Magnesia, lactulose, sorbitol, Miralax) Avoid stimulants such as senna or dulcolax, except for occasional use 2. Nausea Use metoclopropramide (Reglan) or compazine; avoid phenergan (see below) 3. Somnolence reduce dose of narcotic reduce or discontinue other medications that may be contributing to the somnolence Concomitant prescription/OTC drugs 1. Acetaminophen: exercise caution when prescribing combination narcoticacetaminophen drugs to ensure that total daily dose of acetaminophen does not exceed 4.0 grams or, in persons with liver disease/impairment, 2.0 grams 2. Benzodiazepines Concomitant use of benzodiazepines is not recommended Any patient on benzodiazepines who wishes to take narcotics should be tapered off the benzodiazepine, or must be followed by a psychiatric provider who prescribes the benzodiazepine or must be evaluated by a psychiatric provider for appropriateness of prescription Particular caution should be exercised when prescribing a long-acting narcotic for a patient taking benzodiazepines Consider working with psychiatric provider to reduce dose of benzodiazepines for any patient on narcotics Positive drug screen for benzodiazepines that are not prescribed should prompt reconsideration of opiate prescription because of risk inherent in combining opiates with uncontrolled and unmonitored benzodiazepines

3. Medical Marijuana Concomitant use of marijuana is not recommended New patients (unless they have compelling reasons for use, e.g., HIV/AIDS, multiple sclerosis, cancer) who admit to using marijuana or who have a positive marijuana screen will not be prescribed opiates unless they agree to discontinue marijuana Established chronic pain patients who are stable and have no problematic behaviors and who have positive marijuana in UDS may continue to get opiates at PCP discretion; covering providers will honor decision made by PCP Patients who present with a request for PCP to sign state verification for medical marijuana card for chronic pain: PCP may opt to sign state forms or document diagnosis on progress note and give a copy to the patient for documentation or refuse request. 4. Phenergan Concomitant use of phenergan is not recommended; a patient request for phenergan by name should raise suspicion of opiate abuse/dependence New patients will not be prescribed phenergan Provider may prescribe metoclopropamide (Reglan) or compazine for nausea; Reglan is available on uninsured formulary Established patients on opiates and phenergan with no problematic behaviors may be continued on phenergan at PCP discretion; covering providers will honor decision made by PC 5. Carisoprodol (Soma): avoid use. May be abused or diverted. 6. Barbituates: avoid use due to additive sedating effects 7. Quetiapine (Seroquel): potential for abuse secondary to high street value due to its known sedative and anxiolytic qualities. There are reports of intranasal pulverized pills use/abuse in the opiate addicted/ abusing populations. Not on MCHD formulary and represents a significant pharmacy cost. Recommend caution with prescribing. Recommend mental health evaluation to justify ongoing use of medication. Contract/Agreement Violations 1. Provider should respond to every violation of the agreement, including no shows, and document response in chart 2. Violations most likely to predict abuse Stealing or borrowing drugs from another patient Obtaining drugs from a non-medical source Concurrent abuse of related illicit drugs Injecting drugs meant for oral use

Multiple unsanctioned dose escalations Recurrent (more than once) loss or theft of prescriptions

3. Violations less likely to predict abuse Aggressive complaining about the need for higher doses Drug hoarding during periods of reduced symptoms Requests for specific drugs Acquisition of similar drugs from other medical sources Unsanctioned dose escalation one or two times Unapproved use of the drug to treat other symptoms Reporting unexpected CNS effects 4. Repeated violations of the agreement should prompt careful reassessment of appropriateness of narcotic prescription; discontinuation may be best choice

Management of Specific Contract/Agreement Violations 1. Early refill request or running out and getting supply from outside provider Evaluate patient for appropriate level of pain control; patient may need dose escalation Evaluate for narcotic abuse and discontinue if appropriate Consider psychiatric evaluation; patient may be abusing medication to relieve psychiatric symptoms Counsel patient that repeated, abrupt withdrawal from pain medication which results from early exhaustion of drug supply can compromise good pain management Patients with genuine pain issues and intractable abuse of prescription opiates are sometimes effectively managed through methadone maintenance; consult with medical director of methadone maintenance program 2. Presence of drugs of abuse in urine A positive screen for drugs of abuse is rarely a false positive If not already enrolled in nursing case management program, refer all patients with + UDS for drugs of abuse into nursing case management for enhanced assessment and management and transition patient to tramadol (see below) 3. Absence of prescribed drug in urine Absence of short-acting opiate in urine does not necessarily mean patient is not taking the medication, especially with oxycodone, or when patient uses low doses or takes medication intermittently; if diversion is a concern, see below. Absence of long-acting opiate in urine is presumptive evidence that patient has not taken the drug o patient may have run out early and should be evaluated as above

o patient may not be taking regularly, in which case a long-acting medication may not be appropriate o patient may be diverting medication (see below) and medication should be discontinued Currently, MCHD uses Quest Laboratories for Urine Drug Screening In general, the DAP 10-50 or DAP 10-50 with Ethanol are ordered In certain circumstances a special test is required as the drug may not result with a DAP 10-50 UDS See attached cheat sheet to assist with interpreting the Urine Drug Screen DAP 10-50+ (with Ethanol) Result
Amphetamine Ethanol Benzodiazepines Cocaine Metabolite N/A Propoxyphene Hydromorphone N/A Morphine/ Codeine N/A Hydrocodone and/or Hydromorphone THC

Drug
Adderall Alcohol Benzodiazepines Cocaine Concerta Darvocet Dilaudid Fentanyl Heroin Klonopin Lortab Marijuana

DAP 10-50 Result

Amphetamine Ethanol Benzodiazepines Cocaine Metabolite N/A Propoxyphene Hydromorphone N/A Morphine/ Codeine N/A Hydrocodone and/or Hydromorphone THC

Special Test Required

Not Needed Not Needed Not Needed Not Needed Send Out Confirmation Not Needed Not Needed Send Out Confirmation Not Needed Send Out Confirmation Not Needed Not Needed

Special Test Code

N/A N/A N/A N/A 21108 N/A N/A 6135 N/A 3483 N/A N/A

Other Iss
Should not see

Does NOT inclu (Cocaine Metab Benzoylecgonin

Also known as Generally not re secondary to la potential cardia Should not see

Cannot distingu codeine or popp

Also spelled Clo Hydrocodone m Hydromorphone

Methadone

Methadone

Methadone

Not Needed

N/A

Will only report Methadone Met So NO methado methadone is b

Methamphetamine Morphine MS Contin

Methamphetamine and/or Amphetamine Morphine Morphine

Methamphetamine and/or Amphetamine Morphine Morphine

Not Needed Not Needed Not Needed

N/A N/A N/A

If unclear can s Amphetamine I 3053) L-isomer isomer is the st

Oxycontin

Large amounts may be noted on report as Oxycodone Large amounts may be noted on report as Oxycodone Large amounts may be noted on report as Oxycodone N/A

Large amounts may be noted on report as Oxycodone Large amounts may be noted on report as Oxycodone Large amounts may be noted on report as Oxycodone N/A

Oxycodone Confirmation by GC/MS Oxycodone Confirmation by GC/MS Oxycodone Confirmation by GC/MS Send Out Confirmation

36664

To get lower se GC/MS Confirm

Oxycodone

36664

To get lower se GC/MS Confirm

Percocet Ritalin

36664 21108 Must Hand Write Test Name N/A N/A

To get lower se GC/MS Confirm Also known as

Strattera Tylenol with Codeine Vicodin

N/A Codeine and/or Morphine Hydrocodone and/or Hydromorphone

N/A Codeine and/or Morphine Hydrocodone and/or Hydromorphone

Send Out Confirmation Not Needed Not Needed

Also called Atom

Unable to distin Hydrocodone m Hydromorphone

5. Suspected diversion Documented sale of prescription drugs should result in immediate and permanent termination of all prescriptions for scheduled drugs For unsubstantiated reports or absence of drug in urine o Increase frequency of UDS o Prescribe only long-acting opiate which can be reliably monitored in the urine o Utilize mid-month, random (without prior notification) recall to the clinic for pill counts and UDS. Less than expected number of pills coupled with a negative UDS is presumptive evidence of diversion and medication should be discontinued.

Weaning Opiates Opiates must be weaned after chronic use. In general patients who have been on regular doses of opiates for over a month should be weaned. 1. Decrease dose by 10% per week for long-acting opiates, 15% per week for short acting 2. Consider use of Clonidine to minimize side effects a. 0.1mg 0.2mg po q 6 hrs 3. Opiate withdrawal symptoms are uncomfortable but not dangerous 4. Anticipate increased need for behavioral health support during this process

5. Provide careful written instructions, documented in the record, as to how to wean down on opiates.

Opiate Addiction, Methadone Maintenance and Pain Management 1. Persons who have a history of opiate addiction may have a lower pain threshold and may require higher doses of opiates to effectively manage their pain 2. Persons who are actively abusing prescription or non-prescription opiates should not be prescribed opiates 3. Persons with uncontrolled chronic pain who are enrolled in methadone maintenance: do not prescribe additional short-acting opiates, including tramadol, for break-through pain do not prescribe extra doses of methadone or any other long-acting opiate to supplement the methadone maintenance dose consult with medical director of methadone maintenance program to consider: split-dosing of methadone or increased dose of methadone to improve pain control methadone maintenance program managing the methadone dose changes 4. Persons with chronic pain who are enrolled in methadone maintenance and who wish to discontinue methadone for treatment of opiate dependence, but continue methadone treatment of pain: it is legal for a PCP to treat a person formerly in methadone maintenance with methadone for pain management if the patient is no longer in methadone maintenance, manage the same as any other new patient if the patient is currently in methadone maintenance, consult with medical director and counselor at methadone maintenance regarding the stability of the patients medication management and appropriateness of transition out of methadone maintenance into primary care management of chronic pain with methadone o these patients will invariably require much higher doses of methadone to manage their pain than methadone nave patients o have the patient taper down to the lowest dose of methadone possible that still provides adequate pain relief, before the patient transitions to primary care o arrange a specific day for transition that is agreed to by all parties, ie, patient receives a final dose of methadone at the methadone program and is seen the following day in primary care for a prescription of methadone o split the dose of methadone into at least twice daily dosing

o document clearly in the chart and ensure that patient understands that you are prescribing methadone to manage pain and not to manage opiate addiction

Nursing Case Management of Pain Patients at Risk for Misuse, Abuse, or Diversion Provider Guidelines (See attached workflow) Purpose: to optimize treatment of chronic pain in patients with risk factors for abuse and/or diversion while minimizing the risk of abuse and diversion Provider may refer either new patients or established patients with moderate or high risk for misuse, abuse or diversion using Opiate Abuse Tool (appended). Provider responsibilities: 1. Assess pain and establish diagnosis 2. Determine risk for abuse or diversion using Opiate Abuse Tool; abstract risk score onto problem list 3. May refer both new and established patients with moderate or high risk scores 4. Refer to nurse case manager for nursing assessment and management 5. Obtain UDS at time of referral 6. Obtain ROI for all relevant past medical records 7. Provide initial prescription of pain medication Maximize non-narcotic medication therapy first (can include: NSAIDS, Tramadol, Elavil, Neurontin) If non-narcotic medication is contraindicated or ineffective, prescribe only low dose, short-acting narcotics (<= 40 mg oxycodone, <=60 mg vicodin) 8. Patients who enter system on high doses of narcotics which put the patient at risk for withdrawal if discontinued abruptly Current dose of narcotics must be documented by confirmation through one of the following: o Pill vial with current date o Phone confirmation with patients pharmacy o Phone confirmation with patients former provider o Records that patient brings with them to the visit may not be complete and are not considered a reliable confirmation of current dosing

 Once drug and dose are confirmed and neither abuse nor diversion is evident, provider may continue current drug(s) at current doses Enroll patient in nurse case management for pain management One or two week supply of medication only is recommended until assessment of patient is complete 9. Provide prescriptions for opiates, if indicated, when patient: has clean UDS q week for 4 weeks, then q 2 weeks for 4 weeks (with pill counts on alternating weeks) has complied with all aspects of treatment plan has no problematic behaviors 10. Methadone is the drug of choice for all patients, unless contraindicated, because it can be reliably monitored in the urine obtaining specific methadone consent is not required, but is recommended Start at 2.5 - 5 mg BID and titrate upward Avoid concomitant use of short-acting opiates 11. Obtain narcotic pain medication information and consent prior to first narcotic prescription 12. Re-evaluate patient at 3-6 month intervals 13. Manage contract violations, as above 14. If patient is stable with no problematic behaviors for 6-12 months consider discharge from nursing case management 15. If patient suffers a relapse (+UDS) or problematic behaviors occur after a period of stability, discontinue the narcotic and return patient to intensive nurse case management for at least 4 weeks, at provider discretion 16. Infrequent (<= once per year) and brief (single episodes) relapses in a patient who is otherwise stable and fully participates in recovery activities can be managed as an expected part of recovery; the opportunity to continue to receive narcotic pain management can act as a powerful incentive to these persons to remain in recovery 17. Two or more relapses in a 12 month period should prompt discontinuation of narcotic pain management until the patient has achieved 12 months of abstinence.

Nursing Standing Orders for Chronic Pain Management with Opiates Initial Assessment: Subjective: 1. 2. 3. 4. 5. Location and severity (pain scale) of pain Inciting and relieving factors Associated symptoms Activities patient could do if his/her pain were better controlled Current pain-related medications and doses (include narcotics, Tylenol, NSAIDS, anti-emetics, muscle relaxants, medical marijuana) 6. Non-medication treatment modalities 7. Past history of mental health treatment or diagnosis 8. Current mental health treatment or diagnosis 9. Current and past substance abuse (illicit, prescription, alcohol) 10. Current and past substance abuse treatment 11. Current legal status, ie, patient on probation or parole Objective 1. Dates and Results of most recent UDS 2. Opioid risk score Assessment: May include: 1. chronic pain syndrome 2. Substance abuse 3. chronic mental illness 4. H/O of substance abuse 5. H/O mental illness Plan 1. Review and sign Pain Treatment Information and Consent 2. Agree on and document patient activity (function) goals

3. Appropriate stretching, exercise, relaxation, distraction 4. Referral as needed to: pain class psychiatric nurse practitioner social work Drug Assistance Program 5. ROI as needed for Mental health provider Former PCP PO 6. UDS (note last dose of narcotics taken, if applicable) 7. Obtain current pain medication order (consult provider) 8. Schedule return appt with nurse case manager q week for four weeks, then q two weeks for 8 weeks; follow up q 4 weeks when stable and compliant Follow up visits: Subjective: 1. pain intensity 2. level of functioning related to activity goals 3. side effects to pain-related medications 4. compliance with plan established at previous visit 5. Nutririon and hydration review 6. LOC and mental status Objective: UDS results Otherwise as indicated Observation of skin, eyes Weight and vital signs Assessment (as applicable) 1. chronic pain: worse, stable or improved 2. mental health: worse, stable or improved 3. substance abuse: relapse or continued recovery Plan: 1. 2. 3. 4. 5. Consult with provider if patient violates pain treatment agreement Arrange follow up per protocol UDS obtain pain medication order Schedule a series of visits as indicated by the findings for regular case management or for intensive case management

Attachments: 1. 2. 3. 4. 5. AGN.06.01 Narcotic Agreement AGN.01.13 Methadone Consent Informed consent for patient/materials risk Nurse Case Management Workflow Make UDS screening tool an attachment